Upper Eyelid Reconstruction after Mohs Surgical Excision - A Pictorial Essay
Updated: May 14, 2020
* Warning: the following article has graphic content that may be disturbing to some.
I had the pleasure of meeting a very pleasant lady a few months ago who was referred to me for a lesion on her left upper eyelid.
Upon seeing her, I performed a biopsy of the lesion (below, arrow), which came back from pathology as a malignant skin cancer. Skin cancers of the eyelids and around the eyes are not uncommon, as these areas are constantly exposed to the sun.
In light of these findings, I then referred her to a Mohs dermatologist so that a full excision of the skin cancer and subsequent reconstruction of the eyelid can be coordinated.
Using Mohs micrographic surgical techniques, layers of the lesion were systematically and serially excised then examined immediately under a microscope. This technique allows the minimum amount of eyelid skin to be removed, while ensuring that the cancer is fully excised. This greatly facilitates any reconstructive efforts and provides the best results for the patient.
After full excision of the skin cancer, I began reconstructing the full thickness defect of the eyelid (below, arrow).
In order to reconstruct the full thickness of an eyelid, one must have an understanding of the anatomy of the eyelid and the layers that comprise it. First, skin covers the front (or anterior) surface of the eyelid. Underneath the skin, is a layer of muscle called the orbicularis oculi muscle, which is responsible for eyelid closure and blinking. Together, the skin and the orbicularis muscle layers form what is called the anterior lamella of the eyelid. Behind this layer is the tarsal plate, which gives structural support to the eyelid, and the conjunctiva, the surface lining of the eye and eyelid. Both the tarsal plate and the conjunctiva form the posterior lamella. Therefore, reconstructing the eyelid involves rebuilding the anterior lamella as well as the posterior lamella.
The challenge of reconstructing any surgical defect requiring multiple layers is maintaining a healthy blood supply to the transplanted tissue. Without adequate blood supply, the tissue simply will not survive. For this reason, a free graft, i.e., tissue that is cut free from its blood supply and transferred to a defect, depends on the blood supply of the recipient bed for survival. Therefore, more than one free graft transferred to the same area will not survive and is generally avoided. As such, advancement flaps, i.e., tissues that are advanced onto a defect with their own blood supply attached, can be of great utility.
While there are various methods to reconstructing the eyelid, I chose a well-known technique called the Cutler-Beard bridging flap procedure. This procedure was first described by Norman Cutler and Crowell Beard in 1955 and has undergone various modern modifications since then. However, it remains one of the most common techniques for full thickness reconstruction of the upper eyelid.
The general principles behind a Cutler-Beard procedure are as such: a free graft is used to replace the tarsal plate, a conjunctival advancement flap from the lower eyelid is used to replace the conjunctiva, and a skin-orbicularis muscle bridging flap is advanced from the lower eyelid. This allows reconstruction of both the anterior lamella and the posterior lamella while maintaining adequate blood supply to the tissues. After healing, and once the flaps develop their own blood supply in their new environment, they are then severed, thus restoring eyelid anatomy.
First, I advanced a conjunctival flap from the opposite (i.e., lower) eyelid and sutured it to the back side of the upper eyelid defect. Then, I harvested a free graft from the fellow (i.e. right) upper eyelid tarsal plate and secured it to the defect. I then raised a skin-orbicularis muscle flap, advanced it onto the defect under a lower eyelid bridge, and sutured it over the free tarsal graft, effectively rebuilding both the anterior lamella and the posterior lamella.
Since flaps were advanced from the lower eyelid, the lids had to be closed shut until they were fully healed.
After six weeks and once the flaps were healed and adequate blood supply was achieved, the flaps were severed, re-opening the eye and restoring the anatomy of the upper eyelid.
Most importantly, with the assistance of my colleague in dermatology, we were able to fully remove the cancer, reconstruct the eyelid, and have a happy patient.
These are images of actual patients of Dr. Jean-Paul Abboud. They are shown for informational purposes only and are provided with written patient consent for use on this website. Please do not copy or distribute images/videos. Each individual’s treatment and/or results will vary, and no guarantee is stated or implied by any photo or statement used on this website.